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I observed the young man lay dying with terminal cancer, and his grieving family members in yellow gowns and surgical masks. His sputum bacteriological culture report stated, ‘This patient’s sputum is growing methicillin-resistant Staphylococcus aureus. Please examine him for management'. Writing briefly about the futility of treatment in the medical note, I invited the nurse to contact me if any of the team members felt the need for changing the direction of care. The patient died within that hour.

Evidently, this is an extreme example; it nevertheless illustrates our attitude towards antibiotic use in terminally ill patients and difficulties in decision-making. By ‘terminally ill’, I refer to patients with terminal cancer or chronic diseases, who may not survive beyond 2–3 days,1 often have advanced directives, or are issued ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions. End-of-life care should be implemented in transitioning from life-prolonging treatment to maintaining maximal comfort and dignity without unacceptable side effects.1

However, antibiotics are commonly prescribed for terminal patients, often until the last moment,2 even without evidence of infection2 in many countries including Hong Kong.2–6

Many reasons are possible.

Infections are common in terminal patients due to their immunocompromised state and other underlying conditions; many have febrile episodes2 and often suffer multiple disease-related symptoms, which, including patients’ downhill clinical course, closely resemble sepsis. Believing that the infection, often hospital acquired, is …

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